A small but growing literature suggests that cognitive-behavioral therapy (CBT) is an effective treatment for survivors of rape or war-zone trauma who develop posttraumatic stress disorder (PTSD), but there are no published studies testing CBT in PTSD patients who have been exposed to childhood sexual abuse. Furthermore, previous CBT treatment outcome studies have not monitored its effect on psychophysiological and neurobiological abnormalities known to be associated with PTSD. To address both of these issues, a randomized clinical trial is proposed that will evaluate CBT in a sample of women with PTSD secondary to childhood sexual abuse. The specific aims of this project are: 1) to implement a cognitive- behavioral treatment program; 2) to provide comprehensive, longitudinal assessment of PTSD symptoms, co-occurring psychiatric problems, psychophysiological reactivity, and neurohormonal levels; and 3) to test hypotheses concerning the immediate and long-term effectiveness of CBT in comparison to supportive counseling (SC) and wait-list controls. Eighty-four female outpatients with PTSD secondary to childhood sexual abuse will be randomly assigned to one of the two active-treatment groups, CBT or SC, or to a wait-list control group. All of the women will be assessed initially and after fourteen sessions of treatment (or in the case of the wait-list control group, after nine weeks) using structured interviews and self-report questionnaires. In addition, both the standard psychophysiological measures for assessing PTSD (heart rate, skin conductance, and facial EMG) and supplementary measures of cardiovascular reactivity (cardiac output, pre-ejection period, and total peripheral resistance) will be obtained initially and immediately following treatment upon exposure to trauma-unrelated and trauma-related passive- and active- coping tasks. Twenty-four hour urinary-free cortisol, epinephrine, and norepinephrine, as well as thyroid hormone profiles, will also be measured. The two active-treatment groups will undergo the same assessment six months after completing treatment and will receive an interim psychometric assessment three months after treatment. We hypothesize that CBT will be more effective than both SC and wait-list: 1) in reducing PTSD symptoms; 2) in decreasing the magnitude of psychophysiological responses to laboratory stressors; 3) in normalizing neurohormonal levels; and 4) in reducing depressive, dissociative, and other anxiety symptoms. Besides its clinical value as a treatment outcome study, this project should create an opportunity to test a number of theoretical questions regarding the psychopathology and pathophysiology of PTSD.